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, TATE OF CALIFORN14 WATER RESOURCES CONTRWOARD FORM B': UND GROUND STORAGE TANK PR RAM '... TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 0 2 INTERIM PERMIT E:l 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: &0/ r eh ve FARM TANK-YES❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID# K B. MANUFACTURED BY: C. YEAR INSTALLED (,t,K D. TANK CAPACITY IN GALLONS. Sa GJ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. u I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C a 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL 21 PRODUCT E] 4 GASAHOL 0 5 JET FUEL El 6 AVIATION GAS 5 HAZARDOUS BO EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: zlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH OaERIOR LINER 95 UNKNOWN SYSTEM ® 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEBUIRON ❑ 2STAINLESSSTEEL ❑ 3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE 0 6 POLYVINYLCHLORIDE F-17 ALUMINUM B 100%METHANOL COMPATIBLE FRP 9 BRONZE 0 10 GALVANIZED STEEL ® 95 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES El NO 099 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2TAR OR ASPHALT ❑3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 0 91 NONE ®95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A Q 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(U—)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPRE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AOU 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P S 1 VISUAL CHECK �P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ✓J) P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN PS 99 OTHERAli VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH LA REMAINING IN INERT MATERIAL? F-1YES ONO /T GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 310 C� 1 1 I 1 I F3 I 1010101T] CURRENT LOCAL AGENCY FACILITY ID# APPRO ED By N ME LC/ A��`-"i"�✓'� PHONE M WITH AREA CODE PERMIT NUMBER UPERMIT APPRO AL DA E PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SBIRCH AR AMT FEE CODE RECEIPT# BY: FORM B(3-7-8s) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE'APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY